EMPLOYEE APPLICATION and CHANGE FORM

Transcription

1 EMPLOYEE APPLICATION and CHANGE FORM for individuals in Groups up to 9 Eligible INSTRUCTIONS ALWAYS PRINT CLEARLY USING A BLUE OR BLACK PEN (NO HIGHLIGHTERS) ALWAYS PUT SUBSCRIBER ID NUMBER AND GROUP NUMBER ON APPLICATION. NEW HIRES, LATE ENTRANTS, AND DEPENDENT ADDITIONS MUST COMPLETE THE APPLICATION AND MEDICAL HISTORY QUESTIONNAIRE. OTHER CHANGES COMPLETE ONLY AREA THAT IS CHANGING E.G: DROPPING DEPENDENTS, ADDRESS CHANGE, PHYSICIAN CHANGE, PRODUCT CHANGE... IF WAIVING COVERAGE COMPLETE WAIVER AREA. (Please Print) ABOUT YOUR NEEDS If you have a special language or other cultural need that may affect the administration of your health plan or health care delivery, please indicate below so that Medical Mutual of Ohio could better assist you: Hearing-impaired (require use of TDD/TTY or other means of communication) Vision-impaired (require audio communication or large print document) Speak a primary language other than English (require interpretive services) (please list language) Other cultural need / preference If you do not want any coverage OR if you reject some of the coverage options but accept others, complete this waiver... WAIVER Check One Box in Section A and Complete Sections B and C. A. Waived Coverages: I do NOT want...(check one) HEALTH and LIFE/DISABILITY through Medical Mutual of Ohio (MMO) and MLI HEALTH through MMO LIFE/DISABILITY through MLI Health through MMO for the following dependents only: (Remember to complete the rest of this application) 1) 2) 3) 4) 5) B. Current Health Coverage Status: I have...(check one) Coverage through my Current Employer: Other Insurance Company Name: Coverage through my Spouse's Employer: Spouse's Company Name Spouse's Name Spouse's SS# Other coverage through MMO No coverage Other coverage: C. Authorization: The terms of this waiver are explained in Section 8 of this application. I have read and understand those terms. Current Employer/Company Name: Print Employee Name: Employee Social Security #: Print Spouse Name: Spouse Social Security #: Signature of Employee: Date: WARNINGS: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. (Ohio Revised Code Section ) If you or your family members are covered by more than one health care plan, you may not be able to collect benefits from both plans. Each plan may require you to follow its rules or use specific doctors and hospitals, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other plan that covers you or your family. (Ohio Admin. Code Section ) Z6115 R4/04 1

2 Application Reminders DID YOU FILL IN ALL THE FIELDS IN SECTION 1? IF YOUR EMPLOYER IS OFFERING A CHOICE OF HEALTH COVERAGES, PLEASE COMPLETE THE SECTION AT THE BOTTOM OF PAGE 4. REMEMBER PAGE 1 WAIVER MUST BE COMPLETED IF NOT TAKING HEALTH OR NOT COVERING ONE OF YOUR DEPENDENTS. ALSO PLEASE PUT SOCIAL SECURITY NUMBER OF SPOUSE IF SPOUSE IS WAIVING COVERAGE. DID YOU PUT THE START & END DATE OF PRIOR COVERAGE? DON T FORGET TO SIGN AND DATE...SPOUSE TO SIGN IF MARRIED

3 HEALTH AND LIFE APPLICATION / POLICY CHANGE 1. (Please Print) ABOUT YOU AND YOUR JOB... YOUR LAST NAME YOUR SOCIAL SECURITY NUMBER COMPANY NAME/EMPLOYER GROUP # SECTION YOUR FIRST NAME M.I. YOUR DATE OF BIRTH SEX (M or F) / / YOUR STREET ADDRESS E MAIL ADDRESS OCCUPATION/JOB TITLE EMPLOYEE/CLOCK # DEPARTMENT NAME PAYROLL LOCATION/DEPT. # CITY STATE ZIP CODE FULL TIME DATE OF (RE)HIRE EMPLOYMENT STATUS / / ACTIVE RETIRED COBRA HOME PHONE NUMBER MARITAL STATUS: SINGLE MARRIED DATE MARRIED BUSINESS PHONE COBRA EXPIRATION DATE ( ) - SEPARATED DIVORCED WIDOWED / / ( ) - EXT. / / 2. (Please Print) WHAT YOU WANT DONE... A) NEW POLICY APPLICATION B) CHANGE TO AN EXISTING POLICY 1. Type of Coverage: 1. Date of Change: / / 2. Requested Effective Date: / / PRIMARY COVERAGE: (check only one) 3. Action (Check the Type of Change) SuperMed Classic SuperMed Share SuperMed Plus ADD DEPENDENT TO POLICY (LIST DEPENDENTS IN SECTION 3 BELOW) SuperMed Choice Options (refer to page 4) DELETE DEPENDENT FROM POLICY (LIST DELETED DEPENDENTS IN SECTION 3 BELOW) ADDITIONAL COVERAGE(S): (check all that apply) BENEFIT CHANGE (INDICATE CHOICE TO THE IMMEDIATE LEFT UNDER SECTION A) Dental Vision Life only PRIMARY CARE PHYSICIAN/LOCATION CHANGE (INDICATE CHANGE IN SECTION 3 BELOW) 2. Who Do You Want Covered? NAME CHANGE: FORMER NAME: TERMINATED EMPLOYMENT DECEASED You Only You and One Other Person You and Your Family REQUESTED CANCELLATION Medicare Supplement For: You Spouse Dependent OTHER: 3. (Please Print) ABOUT YOU AND YOUR DEPENDENTS... A. (A)dd Name Sex (C)hange Social Security # Date of Birth (D)elete FIRST NAME LAST NAME (IF DIFFERENT) M or F Spouse SELF Spouse B. Relationship to You: C = Child, SC = Stepchild, AC = Adopted Child*, O = Other* (*attach legal documentation) 4. (Please Print) ABOUT YOUR OTHER HEALTH INSURANCE AND MEDICARE... What date did your most recent health insurance or health benefit program become effective (check box if no prior/current coverage)? / / No Coverage What date did/will the above health insurance or health benefit program terminate? / / Name of Prior Carrier DO YOU OR ANY OF YOUR DEPENDENTS HAVE ANY OTHER HEALTH OR DENTAL COVERAGE? YES NO IF YES, COMPLETE THE SECTION BELOW. NAME OF POLICY HOLDER NAME AND ADDRESS OF OTHER INSURANCE COMPANY POLICY NUMBER EFFECTIVE DATE COVERAGE TYPES WORK STATUS POLICY TYPE Medical Dental Hospital Only Active Single Vision / / Retired Family Prescription Drug Medical Dental Active Single Hospital Only Vision / / Retired Family Prescription Drug MEDICARE INFORMATION: REASON FOR MEDICARE EFFECTIVE DATE: PART A: / / PART B: / / Are you covered by Medicare? YES NO If YES, Medicare No. AGE Is your spouse or dependent YES NO If YES, Medicare No. DISABILITY covered by Medicare? EFFECTIVE DATE: PART A: / / PART B: / / END STAGE RENAL 5. (Please Print) ABOUT YOUR LIFE AND DISABILITY INSURANCE... IF YOUR EMPLOYER OFFERS ANY OF THE FOLLOWING COVERAGES, PLEASE INDICATE IF YOU WOULD LIKE TO ENROLL IN ANY OF THESE COVERAGES AND THE AMOUNT. SHORT TERM LONG TERM BASIC LIFE DEPENDENT LIFE SUPPLEMENTAL LIFE SUPPLEMENTAL AD&D DISABILITY DISABILITY YES NO YES NO YES (AMT. $ ) NO YES (AMT. $ ) NO YES NO YES NO IF ANY YES BOX IS CHECKED ABOVE, COMPLETE THE REMAINDER OF THIS SECTION. GROUP/DIVISION NUMBER: CLASS: SALARY HOURLY WEEKLY FOR MLI USE ONLY $ MONTHLY ANNUAL EFFECTIVE DATE: / / Social Security Number Beneficiary Last Name Beneficiary First Name Date of Birth Relationship Benefit Split** PRIMARY % SECONDARY % ** Unless otherwise noted, if two primary beneficiaries are named, the proceeds will be paid in equal shares to the primary beneficiaries surviving you. 6. SIGNATURES - Sign after completing and reading all applicable sections (including front of this application). I have read all of the statements contained in this application, and declare by signing this application that I am an active, eligible, compensated, full-time employee and that the information I have provided is true and complete to the best of my knowledge. Signature of Spouse authorizes release of information described on the front of this application. Your Signature Date Your Spouse's Signature (if applying for dependent coverage) Date 2

4 Application Reminders DON T FORGET HEIGHT AND WEIGHT!! IF YOU CHECKED YES FOR ANY CONDITION THEN COMPLETE SECTION 7C MAKE SURE TO WRITE AN EXPLANATION HERE!

5 MEDICAL HISTORY QUESTIONNAIRE (for groups with up to 9 eligible employees) 7. Last Applicant Social Security Number Group Number Date of Birth Height Weight Dependents (Full Name) Date of Birth Height Weight Dependents (Full Name) Date of Birth Height Weight Spouse A. Check all medical conditions, diseases listed below for which you or any of your dependents have, or have ever been diagnosed, treated or counselled: (Use number and letter to identify conditions in 7C) 1. Transplant (any organ) 19. Other Lung Disorders 36. Coronary Artery Disease 2. Connective Tissue Disease 20. Liver Disorders 37. Bypass Surgery 3. A.I.D.S./A.R.C./H.I.V. 21. Congenital Disease/Defect 38. Congestive Heart Failure 4. Arthritis, Osteo 22. Paralysis 39. Pacemaker 5. Arthritis, Rheumatoid 23. Multiple Sclerosis 40. Ischemic Heart Disease 6. Back/Spinal Disorder 24. Cerebral Palsy 41. Other Heart Disorders 7. Scoliosis 25. Epilepsy 42. High Blood Pressure 8. Spina Bifida 26. Parkinson's 43. Yes, Give Last 3 Blood Pressures & Dates 9. Ulcerative Colitis 27. Alzheimer's Disease A. B. C. 10. Diverticulitis 28. Other Neurological Disorders 44. Alcohol or Drug Dependency 11. Crohn's Disease 29. Hemophilia 45. Attempted Suicide 12. Gastric/Peptic Ulcer 30. Kidney/Urinary Disorders 46. Anorexia/Bulimia 13. Other Bowel/Stomach Disorders 31. Tumors/Growths 47. Chronic Depression 14. Stroke (Date) 32. Juvenile Diabetes 48. Other Mental/Emotional Disorders 15. Cancer, Leukemia or Melanoma 33. Diabetes Mellitus 49. Venereal Disease 16. Emphysema 34. Yes, Give Last 3 Blood Sugars & Dates 50. Deafness 17. Chronic Bronchitis A. B. C. 51. Currently Pregnant 18. Asthma 35. Heart Attack/M.I. If so, state expected date / / 7B. MEDICAL QUESTIONS 1) Within the past 5 years, have you or your dependents had, or been treated for, or been told Yes No that you have any other condition/disorder/disease not listed above? If yes, explain in 7C. 2) Within the past 5 years, have you or your dependents been hospitalized, operated on or been advised to have an operation which has not yet been performed? If yes, explain in 7C. 3) Have you or any DEPENDENT listed been treated on an outpatient basis: Testing, Rehabilitation, Home Health Care or Emergency Room within the last two years? If yes, explain in 7C. 4) Within the past 5 years, have you or your dependents been on Fertility Drugs, had a High Risk Pregnancy, Abnormal Pap Test, or a Venereal Disease? If yes, explain in 7C. 5) Are you or any of your dependents currently taking any prescription medications? If Yes, indicate medication, reason for taking and dosage per day in Section 7C. 6) Do any of the conditions identified above involve Worker's Compensation? If Yes, provide the Worker's Compensation Case Number: #: 7) Have you or your dependents ever been restricted from, or declined for coverage by any carrier? If yes, explain in 7C. 7C. Condition/ Question # Individual (FULL NAME) Physician's Name and Address EXPLANATION Treatment Dates (FROM /TO) Diagnosis, Treatment, Prognosis, Medication, Dosage and Reason (be specific) Attach a separate sheet in this format if more space is required. 3

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7 8. THE EXPLANATION OF WAIVER I understand that if I check any box in Question A of the Waiver on the front cover of this application OR check "NO" under any coverages offered in Section 6, that I am choosing not to have those persons covered under the health, life or disability insurance designated and any later application for enrollment and acceptance will be subject to all underwriting requirements. If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enroenrollment within 31 days after the marriage, birth, adoption or placement for adoption. THE TERMS AND WHAT YOU DECLARE 9.I hereby apply to Medical Mutual of Ohio (MMO) and/or to Medical Life Insurance Company (MLI) for the coverage indicated on this application. * I authorize: (1) payroll deduction(s) and remittance of any required contribution for coverage to MMO, MLI and/or any affiliates or divisions of MMO; (2) release of information, without limitation, from any medical/medically-related facility, government agency or person: (a) to evaluate this application for up to 30 months from the date of this application; (b) to adjudicate claims submitted on behalf of me or my dependents as long as I am covered under this policy; (c) for utilization review programs to monitor health services or quality improvement activities; (d) for credentialing purposes. I authorize the applicable carrier to provide a photocopy of this release to any physician or medical institution to obtain records for the purposes stated above. * I understand: (1) any untrue or incomplete information, statements or answers on this application (whether intentional or not), can result in denial of a claim or recision of coverage and may subject me to legal action by MMO or MLI; (2) to be eligible for health coverage, I must be an active full-time employee, as defined by my employer; (3) I must be actively at work, as defined in the group's insurance policy to obtain life and/or disability coverage. If I am not actively at work on the date my life and/or disability coverage would become effective, my coverage will not begin until the day I return to work; (4) if coverage is issued, it will be based on full reliance on the information contained in this application; *I understand and agree that no agent or broker has the authority: (1) to bind MMO by making promises regarding eligibility, benefits, or the issuance of a policy; (2) to waive any answer or any portion of any answer to any question on this application or any information MMO requests; (3) approve coverage; (4) make or alter any contract on behalf of MMO; or (5) waive or alter any of MMO s other rights or requirements. All contract terms must be in writing and signed or accepted in writing by an authorized representative of MMO to be binding on MMO. SUPERMED CHOICE OPTIONS Description Package 1 SM Plus SM Plus 1590 SM Plus 1580 SM Plus 1570 SM Plus Package 2 SM Plus SM Plus SM Plus SM Plus 2000 Package 3 SM Plus 2070 SM Plus 2000 SM Plus 2060 SM Plus 2560 Please Select PRODUCT and INITIAL THE BOX 4